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Open enrollment for 2020 health plans has ended, although residents with qualifying events (including loss of an employer-sponsored health plans) can still enroll or make changes to their coverage for 2020. The next open enrollment period, for plans effective in 2021, will begin November 1, 2020.

Native Americans can enroll year-round, as can anyone eligible for Medicaid or CHIP.

2020: Ten participating insurers; nearly all Ohio residents can choose from among at least 2 insurers

Ten insurers offer plans in Ohio’s exchange for 2020, which was also the case for 2019. But there were some coverage area expansions for 2020, resulting in more choices for some residents. In 2018, there were 42 counties with only one insurer. That dropped to 16 counties as of 2019, and in 2020, Logan County is the only one of Ohio’s 88 counties with just a single insurer in the exchange. The number of counties with only two participating insurers also dropped, from 33 to 29. The rest of the state has at least three insurers offering plans for 2020 (this page lists the insurers offering on-exchange plans in each county in Ohio for 2020).

In 2016, every county in Ohio had plans available in the exchange from at least four carriers, but market upheaval in 2017 and 2018 resulted in insurer exits and concerns that some areas of the state might have had no participating exchange insurers. That never came to pass (details below), but Ohio has since turned a corner in terms of insurer participation in the exchange.

Two of the ten insurers, with a combined total of 46,514 policyholders, implemented average rate decreases. The other eight insurers, with a combined total of 100,140 policyholders, implemented average rate increases.

In August, ACA Signups’ Charles Gaba reported that the Ohio Department of Insurance had indicated that the average approved rate change would be a 7.7 percent decrease. Gaba had also noted earlier in the summer that the Ohio Department of Insurance had curiously noted that insurers’ proposed overall average rate change was a 7 percent decrease, and questioned how that could be possible.

As of late September, the links to the summaries posted by the Ohio Department of Insurance no longer worked. But given the market share of the insurers and their average rate changes, it appears that average premiums in Ohio were increasing for 2020, rather than decreasing. It’s possible, however, that insurers introduced new (lower-cost) plans for 2020, and that the average premiums, including the rates for those plans, ended up being lower than the average premium was in 2019 (based on rate filings, it appears that Medical Mutual, Molina, and Paramount introduced some new plans for 2020; other insurers might also be doing so).

If that’s the case, the average rate change for 2020 did not necessarily reflect average rate changes for people who kept the plans they had in 2019. But it would reflect average rate changes across the entire market from one year to the next, including new plans that weren’t available the previous year.

The introduction of lower-cost plans can be beneficial for people who pay full-price for their coverage and are looking for a lower-priced option. But it can be detrimental for people who get a premium subsidy and want to keep their existing plan. If a lower-cost option is introduced and it ends up taking over the benchmark plan spot, it can result in smaller premium subsidies for everyone in that area. That, in turn, can result in higher net premiums for people who opt to keep their existing plan instead of switching to a new, lower-cost option.

2020 enrollment: Down 19% from peak enrollment in 2016

196,806 people enrolled in private plans through the Ohio exchange during the open enrollment period for 2020 coverage. That was down about 19 percent from the exchange’s peak enrollment, when more than 243,000 people enrolled in 2016. Here’s a summary of sign-ups during open enrollment each year:

This mirrors the general trend that we’ve seen in states that use HealthCare.gov, with enrollment declining from 2016 through 2020. States that run their own exchanges have been much more likely to see increased enrollment during at least one of those years. Numerous factors contributed to the decrease in enrollment: In 2017 and 2018, premiums were sharply higher for people who don’t get premium subsidies. For 2018 and 2019, the Trump administration sharply reduced funding for enrollment assistance and exchange marketing. For 2019, the individual mandate penalty has been eliminated and the Trump Administration expanded access to short-term health plans and association health plans as alternatives to ACA-compliant individual market coverage.

Community Insurance Company (Anthem) and Oscar Buckeye joined the exchange for 2019

Ohio wants to eliminate the individual and employer mandates

Ohio passed legislation in 2015 that requires the state to propose a 1332 waiver that would, if federal permission is granted, allow the state to eliminate the ACA’s individual and employer mandates. In March 2018, the state submitted a 1332 waiver to HHS, requesting the elimination of the individual mandate in Ohio as of January 1, 2019. But HHS deemed the application incomplete, and the state would have to revise it in order to have it reconsidered (that has not happened as of mid-2020).

The federal government has already eliminated the individual mandate penalty as of January 1, 2019, but not the mandate itself (this was done via the Tax Cuts and Jobs Act that GOP lawmakers passed in December 2017). So under federal law, people are still technically required to maintain coverage, but the penalty, if they fail to do so, is now $0. Ohio went ahead and submitted their (ultimately incomplete) 1332 waiver proposal to HHS, requesting the elimination of the mandate itself in Ohio, as of 2019. But the waiver proposal noted that the impact would be negligible since the penalty is $0 in 2019 and beyond.

Ohio has not yet submitted a proposal to eliminate the employer mandate in the state. That change, if proposed and approved, would certainly have an impact on federal revenue, since nothing has changed about the employer mandate penalty, and the federal government is still collecting it. In order to receive federal approval for the elimination of the employer mandate in Ohio, the state would have to demonstrate a way to do so that would be budget-neutral for the federal government. That’s unlikely, given the reduction in employer mandate revenue that would result, along with the likely uptick in the number of people seeking subsidized individual market coverage if their employers were to stop offering coverage.

It’s noteworthy that there are a few states that are taking the opposite approach when it comes to the individual mandate, and have implement state-based individual mandates — with state-based penalties — to replace the federal individual mandate penalty: New Jersey, Massachusetts, California, Rhode Island, and DC all have individual mandates with penalties for non-compliance as of 2020 (Vermont also has an individual mandate in 2020, but the state has not instituted a penalty for non-compliance). Those states are driven by the understanding that an insured population is a healthier population, and that a stable risk pool requires as many healthy enrollees as possible.

Humana, Anthem, and Premier exited at the end of 2017; Oscar joined

Humana announced in early 2017 that they would exit the individual market altogether, nationwide, at the end of 2017. Humana was one of the insurers that offered plans in the Ohio exchange in 2017. But at the end of 2016, Humana sharply reduced its individual market footprint, nationwide. They remained in 11 states (down from 19 in 2016), but only offered plans in a total of 156 counties across those 11 states (for reference, there are 88 counties in Ohio alone).

Anthem also pulled out of the exchange in Ohio, and their individual market offerings in 2018 consisted of a single off-exchange plan in Pike County. This prevented a full market exit in Ohio, allowing them the option to re-enter the state in 2019 — which Anthem did, with plans available in 25 counties. A full statewide exit would have prevented them from returning to Ohio’s individual market for five years, under long-standing HIPAA rules.

There were 67,000 people in Ohio with Anthem coverage who needed to select new plans for 2018. Eleven insurers offered plans in Ohio’s exchange in 2017, but their participation was localized. And in 20 of Ohio’s 88 counties, Anthem was the only participating exchange insurer in 2017 (Anthem was the only insurer in Ohio that offered exchange coverage in every county in 2017).

Premier Health Plan also exited the Ohio exchange at the end of 2017. They continued to offer one bronze plan outside the exchange (in the same 16 western Ohio counties where they offered coverage for 2017), but coverage under that plan ended on March 31, 2018. The rate filing indicated that only 40 members were expected to have coverage under Premier in 2018. Average rates for the remaining bronze off-exchange plan increased by an average of 34.63 percent in 2018, and anyone who had that plan in the first quarter of 2018 needed to purchase a new plan with coverage effective April 1, 2018. Premier noted in their rate filing that “members who choose to stick with a Premier plan until the exit date are likely to be sicker members who need the plan.”

Initially, 20 counties had no plans filed for 2018. But other insurers agreed to cover them.

When Anthem announced that they would exit the exchange at the end of 2017, there were 20 rural counties — which had more than 11,000 exchange enrollees in 2017 — that did not have any insurers slated to offer exchange coverage. But on July 31, 2017, Ohio’s Department of Insurance announced that five existing exchange insurers had agreed to offer coverage in 19 of the 20 bare counties. Buckeye Health Plan, CareSource, Medical Mutual, Molina, and Paramount Health Care agreed to offer coverage in those counties.

Only Paulding County, in northwest Ohio, was still without any insurers slated to offer coverage at that point. State regulators continued to work with insurers to devise a solution for Paulding County, and On August 24, the Ohio Department of Insurance announced that CareSource had agreed to offer coverage in Paulding County. CareSource offered plans in 51 Ohio counties in 2017, and their 2018 rate filing indicated that they would expand to offer coverage in 59 counties in 2017, although the recent additional expansion further increases that number; CareSource agreed in late July to cover eight of the bare counties, and added a ninth with Paulding.

This happened in other states too, but insurers stepped in to fill the bare spots. Previously “bare” counties in Tennessee, Washington, Kansas, Missouri, Indiana, Wisconsin, and Nevada were all ultimately filled, and all areas of the country had plans available in the exchange in 2018.

In a July 2017 statement, the Ohio Department of Insurance noted that they “will continue working with the industry, but those efforts are heavily dependent on market stability and clarity from Washington. We encourage Congress to work on ways to stabilize our health insurance markets.” Insurers repeatedly stated in 2017 that the best way to stabilize the insurance markets would be for Congress to allocate funding for cost-sharing reductions (CSR) and enforce the individual mandate. But instead, the Trump Administration has cut off CSR funding and refused to commit to robust enforcement of the individual mandate — both of which contributed to a substantial portion of the rate increases that insurers implemented for 2018 plans.

But things were different in 2018 in terms of market stabilization efforts. Insurers in most states, including Ohio, added the cost of CSR to silver plan premiums for 2018, which ended up creating larger premium subsidies and making coverage more affordable for many enrollees. With that strategy, known as “silver loading,” people who don’t qualify for premium subsidies can purchase non-silver plans in order to avoid having to pay the extra premiums that were added to cover the cost of CSR, or can shop off-exchange for silver plans if the state allowed insurers to add the cost of CSR only to on-exchange silver plans (Ohio did allow this, so consumers were well protected for 2018). So while federal funding for CSR was at the top of the list in terms of market stabilization proposals in 2017, that is no longer the case. As long as insurers can continue to add the cost of CSR to silver plan premiums, the lack of federal funding for CSR will not destabilize the market or cause insurers to exit the market.

The seven remaining exchange insurers initially filed 2018 rates based on the assumption that CSR funding would continue in 2018, but the Ohio Department of Insurance later directed them to refile new rates based on the assumption that CSR funding would not continue, and with the cost of CSR added to silver plan premiums for 2018. The Ohio Department of Insurance also allowed insurers to create off-exchange-only silver plans with the same benefits as the on-exchange silver plans, but without the cost of CSR added to the premiums (in areas where such plans are available, they present a good option for people who don’t qualify for premium subsidies, but who want to purchase a silver plan; for people who do qualify for premium subsidies, the additional premiums are offset by larger premium subsidies in the exchange).

In the following list, the approved rate increases are listed first, but the previous filing is also listed to provide perspective in terms of how much the lack of CSR funding drove up premiums for 2018.

AultCare: 29.3 percent. Initially, AultCare had proposed a 10.3 percent increase, and revised it to 13.8 percent in June (the initial filings were based on the assumption that CSR funding would continue in 2018). But in August, they revised it again to an average of 29.3 percent. This was based on the assumption that CSR funding would not continue in 2018, and includes an additional 20 percent premium increase added to on-exchange silver plans. AultCare had 5,848 members.

Ambetter (Buckeye Community Health Plan): 48.9 percent to 49.7 percent, depending on whether the product includes dental and/or vision coverage. Initially, Ambetter proposed a 29.1 percent average increase, which was based on the assumption that CSR funding would continue. They filed the larger average rate increase in August, based on the assumption that CSR funding would not continue. The cost of CSR has been added to on- and off-exchange silver plans. Ambetter/Buckeye had 15,138 members.

Medical Health Insuring Corp. of Ohio (Medical Mutual): 24.5 percent. The previous proposed average increase was 19.8 percent. Medical Mutual noted in their revised filing that they opted to create four new off-exchange-only silver plans with benefits that mirror the on-exchange plans, but without the cost of CSR added to the premiums. Medical Mutual had 23,120 members.

Molina: 37.7 percent increase for Molina Marketplace; 40.5 percent increase for Molina Marketplace Options. The initial proposed average increase was 23.9 percent increase, but the revised filings had substantially higher premiums for silver plans, to cover the cost of CSR. Molina had 20,948 members, and is not marketing products outside of the exchange.

Paramount: 35.92 percent increase. The initial proposed rate increase, based on the assumption that CSR funding would continue, was 20 percent. The cost of CSR has been added to on-exchange silver plans, and Paramount’s revised filing noted that they would offer off-exchange silver plans without the cost of CSR added to the premiums if federal regulators allowed it. Paramount had 3,713 members.

Summa: 41.1 percent increase. The initial filing had an average proposed increase of 26.6 percent. In the revised filing, the cost of CSR has been added to on-exchange silver plans, and Summa notes that they expect to see an increase in the number of people who purchase silver plans outside the exchange (those plans don’t have the cost of CSR included in the premiums, so they’re a good fit for people who want a silver plan but who don’t qualify for premium subsidies to offset the higher rates). Summa has 4,152 members.

16 counties had no gold plans available for 2018

There are 16 counties in Ohio where gold plans were not available in the exchange for 2018 (Auglaize, Coshocton, Crawford, Erie, Hancock, Hardin, Hocking, Holmes, Knox, Marion, Mercer, Ottawa, Putnam, Richland, Williams, and Wyandot). In all of those counties, a single insurer offers coverage (either Medical Mutual or Paramount).

The lack of gold plans in 16 counties is despite the fact that the 2018 Benefit and Payment Parameters, finalized by HHS in late 2016, calls for all insurers in the federally-facilitated exchange to offer at least one gold plan and one silver plan in all parts of their service areas.

The ACA itself requires exchange insurers to offer at least one silver plan and one gold plan, but it doesn’t specify that they must do so in all parts of their service areas. As a result, there were 209 counties (in Iowa, Missouri, Nebraska, and Tennessee) where there were no gold plans available in the exchange in 2016. The rule change for 2018 was an effort to address this issue and ensure that all enrollees have access to at least silver and gold plans.

However, CMS clarified that Ohio has some flexibility on this issue because they’re a plan-management exchange (ie, the state retains plan management functions and certifies plans as qualified health plans to be sold in the exchange). As such, Ohio regulators allowed Medical Mutual and Paramount to offer gold plans in only part of their service areas. Both insurers do offer at least one gold plan in at least some areas of the state, thus satisfying the underlying statute of the ACA.

2017 carriers: InHealth Mutual, Aetna, and All Savers exited the exchange at the end of 2016

Three insurers that offered exchange plans in Ohio in 2016 — InHealth Mutual, Aetna, and All Savers/UnitedHealthcare — did not offer plans in 2017.

And HealthSpan was purchased by Medical Mutual; HealthSpan’s individual market plans ended on December 31, 2016, and were replaced with Medical Mutual coverage — but enrollees had the option to pick a different carrier instead.

The rest of the carriers that offered coverage in the Ohio exchange in 2016 continued to offer plans for 2017. At ACA Signups, Charles Gaba calculated a weighted average rate increase of 17.33 percent for the individual market in Ohio. This was lower than the national average that year, which was about 25 percent.

InHealth Mutual CO-OP liquidated in 2016

InHealth Mutual (Coordinated Health Mutual Inc.) was one of the 23 CO-OPs that were created by the ACA. By the end of 2015, 12 of those CO-OPs had closed, although InHealth Mutual was among the 11 that continued to provide coverage in 2016.

But in May 2016, the Ohio Department of Insurance announced that InHealth would be liquidated, and that 21,800 Ohio residents — most of whom had individual plans — would need to select new coverage. The DOI announced that there would be a 60-day special enrollment period (through July 26, 2016) during which InHealth Mutual members would be able to select new plans.

For members who did not select new plans, InHealth Mutual coverage technically remained in place until the end of 2016. But the state guaranty association stepped in to pay claims, which meant that the coverage was no longer considered minimum essential coverage, and had a benefit cap of $500,000. So a member who continued to pay premiums for InHealth Mutual throughout the rest of 2016 was not in compliance with the ACA’s individual mandate, potentially ending up with a penalty as a result. They also lost eligibility for any subsidies through Healthcare.gov. The Ohio DOI estimated that there were still about 7,800 people with InHealth Mutual coverage as of early August, 2016.

Ironically, InHealth Mutual may have avoided the first round of CO-OP shut-downs because of the fact that they didn’t get their Ohio license in time to offer subsidized plans in the exchange in 2014. As a result, they had to rely on small group enrollments outside the exchange for 2014, and only ended up with 11 percent of their projected enrollment by the end of the year.

But that first wave of 2014 enrollees turned out to be sicker than expected, and nationwide, carriers lost money. Since InHealth Mutual hadn’t been able to offer plans in the exchange, they were spared the high claims that the other CO-OPs experienced, and ended up with a net income of negative $6 million for 2014 (that’s obviously still not good, but only four other CO-OPs did better that year).

By mid-2015, InHealth’s membership had more than tripled, to 22,000 people. But they still had a loss of $9 million during the first half of 2015, and were placed under enhanced regulatory oversight.

For 2016, InHealth had proposed an average rate increase of 7.7 percent, but later revised their request to 15 percent. The final approved average rate increase for their plans was 14.8 percent. However, regulators noted that in order to stem their losses, InHealth would have needed a rate increase of about 60 percent for 2017 if they had remained operational.

2016 carriers and rate changes: Overall rates up about 13%, but benchmark plans were slightly less expensive in 2016

In late October 2015, HHS released an overview of benchmark premium changes in the states that use Healthcare.gov. It was admittedly of limited value, since the benchmark plan isn’t necessarily the same plan from one year to the next. But it did give a good idea of how subsidies would change in 2016, and a general feel for the overall rate change trend in many states. Of the 37 states included on the list, only four had an average decrease in their benchmark premiums — and Ohio was among them. The average second-lowest-cost Silver plan in Ohio was 0.7 percent less expensive in 2016 than it was in 2015.

But according to the Dayton Daily News, overall rates in the Ohio exchange increased by an average of about 13 percent for 2016. However, it’s important to look not just at rate changes, but the rates themselves. According to a Kaiser Family Foundation analysis, a 40-year-old in Cleveland could buy the second-lowest-cost Silver plan for $234/month in 2016, before any subsidies were applied. The analysis examined a major metropolitan area in every state plus DC, and Cleveland, Ohio had the 7th lowest average benchmark price among the 51 exchanges.

Here are the approved average rate changes for the 15 carriers offering plans in Ohio’s exchange for 2016 (some were considerably higher than the carriers proposed):

Fifteen carriers sold 2015 individual plans in the Ohio exchange, up from twelve in 2014. All except Time/Assurant returned to the exchange for 2016. Ohio was tied with Michigan for having the most carriers of any exchange in the country for 2015.

Medicaid expansion in the Buckeye state

Former Ohio Governor John Kasich was not an ACA proponent, but he actively pushed for Medicaid expansion in Ohio, which was approved in late October 2013. Eligible residents were able to begin enrolling in expanded Medicaid on December 9, 2013. Net enrollment in Ohio’s Medicaid program has grown by 23 percent since the fall of 2013.

However, opponents of Medicaid expansion brought a lawsuit against the Ohio Department of Medicaid and the state’s Controlling Board because the General Assembly was bypassed in the decision to expand Medicaid. The plaintiffs hoped to block the state from expanding Medicaid, but on December 20th, 2013 the Ohio Supreme Court sided with Governor Kasich and kept Ohio Medicaid expansion on track. The Court’s ruling came less than two weeks before expanded Medicaid took effect.

Exchange history in Ohio

In November 2012, Governor Kasich formally announced that Ohio would not implement a state-run health insurance exchange. In the same letter, Kasich indicated that Ohio would retain control of plan management activities and determining eligibility for the state’s Medicaid and Children’s Health Insurance Plan (CHIP). Ohio is one of seven states that use the marketplace plan management model.

Leadership’s opposition to the ACA

In June 2013, the Ohio Department of Insurance issued a press release announcing that 14 insurers filed plans to offer more than 200 options for individual insurance, and seven insurers would offer 84 options for small businesses (ultimately, two carriers backed out, leaving 12 in the exchange in 2014). Then-Lt. Gov. Mary Taylor, who also directed the state’s insurance department until 2017, stated in the press release that “consumers will have fewer choices and pay much higher premiums for their health insurance starting in 2014.”

Both opponents and supporters of the Affordable Care Act jumped on the press release. Opponents claimed Ohio was the latest example of “rate shock.” Supporters dismissed the announcement for making “apples-to-oranges” comparisons and pointed out that both Kasich and Taylor had been outspoken about their opposition to the ACA.